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Three Part Question

In [patients presenting to the ED with an acute porphyric attack with hypertension and tachycardia ] are [beta blockers] safe and effective at [reducing blood pressure and heart rate]?

Clinical Scenario

A 43 year old female present to the emergency department with an acute porphyric attack. You wonder if a beta blocker would be safe to use to reduce her heart rate and blood pressure.

Search Strategy

Medline 1966 to 06/06, Embase 1980 to 06/06 and Cinahl 1982 to 06/06 via the Ovid interface
Medline:[exp Adrenergic beta-Antagonists/ or beta blocker.mp. or atenolol.mp. or exp Atenolol/ or propranolol.mp. or exp Propranolol/ ] AND [exp porphyrias/ or porphyria.mp. or porphyrias.mp.] LIMIT humans and english language
Embase and Cinahl: [exp Adrenergic beta-Antagonists/ or beta blocker.mp. or atenolol.mp. or exp Atenolol/ or propranolol.mp. or exp Propranolol/ ] AND [exp porphyria/ or porphyrias.mp. or porphyria.mp. or AIP.mp] LIMIT humans and english language

Search Outcome

Medline: 18 results. 1 relevant
Embase:86 results. 0 new relevant
Cinahl:0 results
Cochrane:32 results-0 relevant
A manual search of papers found for other BETs on acute porphyria revealed one additional result.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Menawat AS, Kocher DK 1979 India	20 patients with acute intemittent porphyria suffering an acute attack. 20 had hypertension and 17 were tachycardic. Propofol was given in doses ranging from 20-200mg.	Case series/open label study. Level 3 evidence.	Control of hypertension and tachcardia	Control achieved in all patients	Case series Urinary PBG not measured
			Symptoms of the acute attack	No symptoms occured
Syned et al 1995 USA	73 year old male with AIP, undergoing bypass surgery. Atenolol 50 mg daily was noted as one of his regular medications.	Case report. Level 3 evidence	Symptoms of an acute attack related to atenolol	No acute attacks	Case report

Comment(s)

Propanolol has been reported to safely controls the symptoms of tachycardia and hypertension in an acute porphyric attack in 21 patients. It has been reported as safe by the university of cape town porphyria service but is not listed as safe or unsafe by The norweigan porphyria centre, Welsh medicines information centre and European porphyria initiative. No reports showing it to be unsafe were found. There is one report of the safe use of atenolol in a porphyric patient.

Clinical Bottom Line

Propanolol appears to be safe and effective at controlling blood pressure in an acute porphyric attack but more research is needed as its safe use has only been documented in a relatively small number of patients. There was insufficient evidence to say whether other beta blockers are safe in acute porphyria therefore more research is needed.

References

1. Menawat AS, Kocher DK Propanolol in acute intermittent porphyria Postgraduate medical journal 1979;55:546-547
2. The welsh medicines information centre Drugs that are considered safe for use in the acute porphyrias
3. The norweigan porphyria centre Drug database for acute porphyria
4. University of Cape Town porphyria service Drug safety;alphabetical listing
5. European Porphyria Initative. Drugs and porphyria
6. Syned et al Use of sufentanil and atracurium anesthesia in a patient with acute porphyria undergoing coronary artery bypass surgery Journal of Cardiothoracic and Vascular Anesthesia 1995:9;75-78